Job Overview This position, in conjunction with Case Management, coordinates the transition of care from one health care setting to another which includes: inpatient, Home Health Care, Skilled Nursing Facility, Rehab facilities. Educates the patient and /or family regarding the patient's clinical condition, treatment, postoperative course, and the patient's role in recovery. Collaborates and communicates with a wide range of multidisciplinary providers with the goal of achieving an exceptional patient experience and the best possible patient outcomes. Job Description Duties and Responsibilities: The duties and responsibilities listed below are intended to describe the general nature of work and are not intended to be an all-inclusive list. Other duties and responsibilities may be assigned. Inpatient CareIdentifies eligible inpatients using established program criteriaDelivers education to the patient and caregivers, including teach back interventionsPerforms risk assessment using standardized toolSupports non-cardiology primary providers with HF guideline directed medical therapies plan, including liaising with pharmacyTransitions of CareCollaborates with other members of inpatient care team to develop discharge care planCoordinates post-discharge care to ensure seamless transitionCollaborates with pharmacist on medication reconciliationSchedules post-discharge clinic appointments Communicates with patient's PCP and post-acute care providers regarding post-discharge care expectationsDevelops a plan for scheduled check-ins with patients and caregiversPost-Discharge CareCalls patient by phone at pre-determined intervalsEnsure patient adherence with care plan (e.g., medications, self-monitoring)Communicates closely with the patient and their family during the first 30 days post-discharge to ensure they are fully informed and supported during the transition periodReminds patients of upcoming appointmentsHelps resolve obstacles to adherence and wellbeingData CollectionCollects and documents key data points into appropriate systems (e.g., risk assessment score)Helps provide QA of appropriate systems to ensure data integrityPerforms interval reviews of readmission cases to identify opportunities for improvementProgram DevelopmentRecommends improvements or development of standards of practice for inpatient, post-acute, home and ambulatory care of patientsParticipates in the development and evaluation of program tools and interventions, such as patient education materials, risk assessment tools, and databasesProvides educational in- and outreach to providers in the networkWorks in collaboration with heart failure disease management NP and RNQualificationsBachelor of Science degree in NursingRegistered nurse with current unrestricted Massachusetts state licenseHeart failure nurse certification highly desirableMinimum of 5 years of clinical nursing experience working with heart failure cardiology patient population Tufts Medicine is a leading integrated health system bringing together the best of academic and community healthcare to deliver exceptional, connected and accessible care experiences to consumers across Massachusetts. Comprised of Tufts Medical Center, Lowell General Hospital, MelroseWakefield Hospital, Lawrence Memorial Hospital of Medford, Care at Home - an expansive home care network, and large integrated physician network. We are an equal opportunity employer and value diversity and inclusion at Tufts Medicine. Tufts Medicine does not discriminate on the basis of race, color, religion, sex, sexual orientation, age, disability, genetic information, veteran status, national origin, gender identity and/or expression, marital status or any other characteristic protected by federal, state or local law. We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation by emailing us at ******.